Ann Thorac Surg 2002;74:927-929
© 2002 The Society of Thoracic Surgeons
Case report
Traumatic extrathoracic lung herniation
Loïc Lang-Lazdunski, MD, PhD*a,
Pierre-Mathieu Bonnet, MDa,
François Pons, MDa,
Louis Brinquin, MDb,
René Jancovici, MDa
a Department of Thoracic Surgery, Percy Military Hospital, Clamart, France
b Department of Anesthesiology, Val-de-Grâce Military Hospital, Paris, France
Accepted for publication April 1, 2002.
* Address reprint requests to: Dr Lang-Lazdunski, Service de Chirurgie Thoracique, Hôpital d’Instruction des Armées Percy, 101 avenue Henri Barbusse BP406, 92141 Clamart cedex, France
e-mail: loic.lang{at}wanadoo.fr
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Abstract
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Traumatic extrathoracic lung herniation is an exceptional complication of blunt chest trauma. We report the case of a 46-year-old man who was involved in a motorcycle accident and who suffered a left clavicle fracture-dislocation associated with multiple rib fractures and massive herniation of the left upper lobe through an upper anterior chest wall defect. Immediate surgical repair through an atypical transcostal vertical thoracotomy resulted in full recovery of pulmonary function at 1 year.
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Introduction
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Traumatic extrathoracic herniation of the lung is of rare occurrence [1]. We report the case of a patient who sustained severe blunt chest trauma and who had massive herniation of the left upper lobe through a large anteroapical chest wall defect created by multiple rib fractures associated with fracture-dislocation of the left clavicle.
A 46-year-old man was involved in a high-speed motorcycle accident. He was projected over a metal rail separating two driveways. Initial clinical examination revealed a herniation of the left lung through an upper anterior chest wall defect and an open fracture of the left femur. Arterial blood pressure was 70/50 mm Hg. He was intubated and ventilated at the scene because of severe respiratory distress and was transported by air to our hospital. He was admitted to the surgical intensive care unit of our institution within 1 hour of trauma and immediately taken to the operating room for surgical repair (Fig 1).
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Fig 1. Initial presentation in the surgical intensive care unit of patient with severe blunt chest trauma, with left clavicle fracture-dislocation associated with multiple rib fractures and massive herniation of the left upper lobe through an upper anterior chest wall defect. The patient was intubated with a single-lumen endotracheal tube at the scene of the accident.
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The herniated left upper lobe was entrapped on the spicules of the left first, second, and third rib fractures. Those ribs were fractured in an usual area corresponding grossly to the anterior axillary line. There was a fracture-dislocation of the left clavicle, the internal third of which had been partly avulsed from the sternum and had been lost at the accident scene (Fig 2).
The subclavian vessels and brachial plexus were totally exposed (Fig 2). The surgeon (R.J.) decided to enlarge the chest wall incision toward the sixth rib, performing an atypical transcostal vertical thoracotomy from the first to the fifth rib to return the herniated left upper lobe to the thoracic cavity without damaging it. Exploration of the pulmonary arteries and veins revealed no avulsion and there was no tracheobronchial injury. Pulmonary lacerations were repaired using running polyglycolic sutures. There was no associated intrathoracic injury. The injured intercostal bundles were ligated on each side of the rib fractures. The ribs were repaired using wire sutures, and the chest wall defect was closed by primary suture and reinforced by muscular flap from the pectoralis major. This muscle was transferred as a pedicled muscular flap based on the thoracoacromial neurovascular bundle and rotated superiorly to cover the upper anterior chest wall defect. Most of the remaining clavicle was resected. The subclavian artery and vein were patent. The brachial plexus was intact. The phrenic nerve looked intact. The pleural cavity and chest wound were copiously irrigated with polyvidone iodine. The chest was closed with two chest tubes and the wound was closed in layers. The patient received 12 units of red blood cells peroperatively.
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Fig 2. Exploration of the thoracic outlet and anterior chest wall. The internal third of the clavicle is partly avulsed and the external third dislocated, exposing the subclavian vessels and brachial plexus, which appear to be intact. The first, second, and third ribs are fractured anteriorly with entrapment of the left upper lobe at this level. There are multiple lacerated intercostal vessels.
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Chest tubes were removed after 4 and 6 days and the patient was mechanically ventilated for 15 days postoperatively. He was discharged from our department on postoperative day 26. Clinical examination at 1 year (Fig 3)
has revealed a good cosmetic result with partial brachial plexus palsy. The patient does not complain of chronic chest pain, and left upper limb Doppler examination reveals patent subclavian artery and vein. Pulmonary function tests show normal values (forced expiratory volume of 1 second, 3.97 L; forced vital capacity, 5.6 L).
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Fig 3. Functional and cosmetic results of surgery at 1 year. The cosmetic result is favorable, and left shoulder function is reported by the patient to be good after 1 year of rehabilitation.
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Comment
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Fewer than 300 traumatic lung herniation cases have been reported since the first record during the sixteenth century [2, 3]. During the past century, motor vehicle accidents, plane crashes, warfare, and terrorism have increased the frequency of this lesion [2–5]. However, massive herniation of the lung through an open wound remains an exceptional complication of combined blunt/penetrating trauma.
The anterior part of the chest wall is the site of predilection for traumatic lung herniations, presumably because it lacks the muscular support afforded the posterior chest wall by the trapezius, latissimus dorsi, and rhomboid muscle [6]. Posttraumatic pulmonary herniations are unlikely to resolve spontaneously, although small herniations have been managed successfully by thoracic strapping in the past [1, 7, 8]. Immediate surgical repair is mandatory for extrathoracic lung herniations, as reported here. The lung can usually be returned to the thoracic cavity, and only rarely is resection of incarcerated lung necessary before closing the chest wall defect. Entrapment of the lung on rib spicules at the site of rib fractures, as occurred in our patient, may require suturing of lacerated parenchyma to prevent air leaks and to shorten hospitalization. Depending on the site of lung herniation, the chest can be entered by means of either an anterior or a posterolateral thoracotomy. In the present case, a large wound in the left upper anterior chest, multiple anterior rib fractures, and left clavicle fracture-dislocation prompted us to perform an atypical transcostal vertical thoracotomy. This approach avoided multiple incisions and allowed treatment of all lesions in a single operative stage. In addition, we had some concern about placing the patient in a lateral decubitus position because of the necessity of exploring the subclavian vessels, phrenic nerve, and brachial plexus. This atypical approach allowed perfect control of lung reintegration into the thoracic cavity and limited damage to the parenchyma during this maneuver. Moreover, this approach allowed adequate exploration of the left thoracic viscera including heart, great vessels, and diaphragm.
With regard to posttraumatic chest wall defects, the smaller ones can usually be closed by primary suture and fixation of adjacent ribs [5]. Larger defects, as in our case, require muscle flaps or a prosthetic mesh for appropriate closure [5]. Broken ribs were repaired using wire sutures, with excellent results. We used a pedicled pectoralis major muscular flap to cover the chest wall defect and the thoracic outlet. Thus, we consider that prosthetic meshes should be avoided as much as possible in those patients with questionable chest wounds, because of the possibility of secondary chest wall infection.
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References
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- Arslanian A., Oliaro A., Donati G., Filosso P.L. Postraumatic pulmonary hernia. J Thorac Cardiovasc Surg 2001;122:619-621.[Free Full Text]
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Abstract
Introduction
